Providing Continuous Home Care In Hospice

Transcription

1 Providing Continuous Home Care In Hospice Katie Wehri, CHPC Director of Operations Consulting Healthcare Provider Solutions, Inc. Objectives Review the CMS regulations for the CHC level of care Identify patient eligibility criteria and expected documentation for this level of care Discuss barriers and benefit to the use of CHC Share applicable scenarios for utilizing this level of care 1

2 The Concerns ARE PROVIDERS OFFERING THE FULL RANGE OF SERVICES? ARE PROVIDERS INAPPROPRIATELY ADMINISTERING THE BENEFIT? Referrals to S & C, Program Integrity Source: Healthcare Market Research, Rich Chesney

3 What Does This Mean for Providers? Review PEPPER results MAC State National Reasons for no CHC Patient characteristics Staffing Hospice inpatient unit Relationship with hospital/snf Source: Healthcare Market Research, Rich Chesney 2016 OIG Report 2015 Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI ) 3

4 Operational and Financial Code/Description FY2017 Rate Proposed FY2018 Rate Continuous Home Care (hourly rate for SIA) $ ($40.19/hour) $ ($40.68/hr.) Rates are not adjusted for wage index, sequester or failure to meet HQRP requirements Operational and Financial Code/Description 2012 OIG - OEI Continuous Home Care percentage of days billed 1% 0.06% FY2014 Freestanding hospice cost reports 4

5 Operational and Financial Code/Description Mean Cost Weighted Mean Cost Continuous Home Care cost of providing care $51 $49 FY2015 cost reports freestanding hospices only Payment rate 2015: $38.75 Operational and Financial Staffing Employed Contracted Clinical Recognizing the need Ability to offer Pressure Partners Consumers Internal? 5

6 Definitions In-patient care or services is defined as short term, general inpatient care provided directly by a hospice program in their own inpatient facility, through a contract arrangement with a licensed Medicare certified long term care facility, or hospital to provide pain and symptom management that cannot be accomplished in another setting. Continuous Home Care is provided in a patient s home during periods of crisis. A period of crisis is defined as a period in which a patient requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms. 11 Regulations: Continuous Home Care CoP Periods of crisis. Nursing care may be covered on a continuous basis for as much as 24 hours a day during periods of crisis as necessary to maintain an individual at home. Either homemaker or home health aide (also known as hospice aide) services or both may be covered on a 24-hour continuous basis during periods of crisis but care during these periods must be predominantly nursing care. A period of crisis is a period in which the individual requires continuous care to achieve palliation and management of acute medical symptoms. 6

7 Regulations: Continuous Home Care CoP Hospice inpatient unit Q5006 Hospital Q5005 SNF Q5004 Nursing facility Q5003 ALF Q5002 Continuous Home Care Calculation of Hours 15-minute increments Minimum of 8 hours of care during a 24-hour day, which begins and ends at midnight. Care need not be continuous, e.g., 4 hours could be provided in the morning and another 4 hours in the evening. Care must be predominately nursing care provided by either RN or LPN. NP hours that in absence of NP would be covered by RN/LPN are counted as skilled nursing care MSW and Pastoral Counselor visits may not be included 7

8 Continuous Home Care Calculation of Hours More than half of the hours of care must be provided by an RN/LPN Homemaker or hospice aide services may be provided to supplement the nursing care. Need for care and or monitoring must be constant - a minimum of 8 hours in a 24 hour period. Overlapping hours counted separately - both must be reasonable and necessary Regulations: Continuous Home Care CoP A hospice may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients under extraordinary or other non-routine circumstances. Generally, a short-term temporary event that was unanticipated. Continuous care is not a highly specialized service, because while time intensive, it does not require highly specialized nursing skills. 8

9 Continuous Care Eligibility Symptom Management: Seizures Nausea/vomiting Uncontrolled pain Collapse of family structure: Caregiver has been providing skilled care and change in patient condition warrants nursing intervention as caregiver no longer can and/or wishes to provide care. Continuous Care Eligibility Pain Requiring: Delivery of medication which may require skilled nursing care for calibration, tubing change or site care/adjustment due to the complexity, nature of the medication and it s delivery system Frequent evaluation/assessments by nurse or physician Aggressive treatment to control pain Frequent medication adjustments 9

10 Continuous Care Eligibility Symptom changes: Sudden deterioration requiring intensive nursing intervention Uncontrolled nausea or vomiting Pathological fractures Respiratory distress that becomes unmanageable Severe agitated delirium or anxiety or depression secondary to end-stage disease process When Continuous Care Is Not Allowed Actively dying and not meeting the criteria for period of crisis Caregiver breakdown, unless patient need meets criteria Unsafe home situation To maintain the patient in their own home (no period of crisis) While awaiting nursing home placement 10

11 Continuous Home Care Clues Multiple calls High or increasing anxiety Multiple visits without resolution/difficulty managing symptoms Continuous Care Documentation Tips Do Document At least hourly Time in/time out What care needs are not being met and why they qualify as a period of crisis Team collaboration Involvement of MSW, Chaplain, Volunteers, Physician, etc. Team s effort to resolve patient problems at the lowest level of care 11

12 Continuous Care Documentation Tips Do Document Specific symptoms that need to be controlled Interventions implemented and patient s response RN/LPN summary and plan for continuing CHC Care coordination with facility staff, if appropriate Resolution of crisis That patient is at risk for hospitalization if symptoms and or care needs are not managed and or met Continuous Care Documentation Tips Don t Include the following in calculation of hours documentation time, hospice aide supervision, care plan changes hand off/reporting lunch/breaks education Include non-allowed discipline time in continuous care hours calculation Discount hours 12

13 Continuous Home Care Documentation Tips Address the following: 1. What caused this period of crisis Change in comprehensive assessment Collaboration with team 2. What interventions were implemented and patient response Change in plan of care Patient response to interventions 1. Resolution of Crisis Change in comprehensive assessment Change in plan of care Collaboration with team Continuous Home Care Program Revocations for urgent treatment/911 Discharges non-contracted facilities Hospitalizations Daily visits Multiple calls using the on-call system CAHPS Hospice Survey comments Complaints 13

14 Continuous Home Care Program Estimate number of continuous home care hours Estimate number of discipline hours Evaluate skill set/competencies and develop plan for education Estimate cost and revenue Continuous Home Care Program Approval from supervisor prior to implementation Pre-billing audit Documentation supports period of crisis for all hours to be billed No contracted staff utilized unless exceptions met Provided in allowable location Calculation of hours is correct More than half is nursing Hours not discounted Non-allowable activities not included RN/LPN and aide hours only Staff documentation time in/time out matches hours to be billed 14

15 Documentation Tips Create a snapshot that will paint a picture of the patient s needs and what the care needs entail. The picture you paint is the picture Medicare will use to determine whether this level of care is appropriate and reimbursable

16 References IAHHC (2012) Hospice Continuous Care Criteria, Strauss and Wehri CFR Title 42- Public Health, Part 418-Hospice Care Electronic Code of Federal Regulations (2012) Hospice & Palliative Care Federation of Massachusetts (2008), The Hospice General In-Patient Level of Care; Criteria, Guidelines, Reimbursement and Contracting Medicare Benefit Policy Manual, Chapter 9 CMS State Operations Manual, Appendix M Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf Medicare Claims Processing Manual, Chapter 11 Guidance/Guidance/Manuals/Downloads/clm104c11.pdf Katie Wehri, CHPC Director of Operations Consulting Healthcare Provider Solutions, Inc. 810 Royal Parkway, Suite 200 Nashville, TN info@healthcareprovidersolutions.com 16